Journal of

Orthopaedic
Article Surger y
Journal of Orthopaedic Surgery
27(1) 1–8
ª The Author(s) 2019
Use of smartphone to improve Article reuse guidelines:
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acetabular component positioning DOI: 10.1177/2309499019825578
journals.sagepub.com/home/osj

in total hip athroplasty: A comparative

clinical study

Anuwat Pongkunakorn, Swist Chatmaitri

and Kittipong Diewwattanawiwat

Abstract
Background: The position of the acetabular cup is important to the outcome of total hip athroplasty (THA). We
devised an instrument that uses the level indicator application of smartphone together with a mechanical alignment
guide to improve the precision of cup placement. This study aims to determine the percentage of acetabular cups
positioned in the Lewinnek safe zone comparing between the conventional technique (using a mechanical alignment
guide alone) and the smartphone technique (using a mechanical alignment guide combined with the devised
instrument and smartphone). Methods: A historical controlled trial was conducted among 82 patients who
underwent primary THAs through a posterolateral approach. In the conventional group, 41 cups were placed during
January 2013 and December 2014, whereas 41 cups in the smartphone group were placed during January 2015
and March 2016. Inclination and anteversion angles were measured in standardized pelvic radiographs. The cup
orientation was compared between groups. Results: The inclination angle in the smartphone group was significantly
lower than in the conventional group (40.9 (SD 3.8) vs. 46.3 (SD 6.7), p < 0.001), but the anteversion angle was higher
(19.6 (SD 4.4) vs. 16.5 (SD 6.1), p ¼ 0.010). The smartphone group had more cups positioned in the Lewinnek safe zone
(90.2% vs. 56.1%, p ¼ 0.001) and longer operative times (136 (SD 27) vs. 119 (SD 23) min, p ¼ 0.011). No significant
difference was found for blood loss (p=¼ 0.384) or dislocation rate (p ¼ 0.494). Conclusion: Using the computerized
function of smartphone could improve the precision of cup positioning. Most cups were placed within a narrow margin
inside the Lewinnek safe zone.

Keywords
acetabular cup positioning, pelvic inclinometer, smartphone, total hip arthroplasty

Date received: 18 May 2018; Received revised 27 September 2018; accepted: 30 December 2018

Introduction
The acetabular component positioning is highly important
to the function and outcome of total hip arthroplasty
(THA). Achieving the optimal inclination and anteversion
could potentially improve the longevity and range of
motion of a THA and decrease the dislocation rate.1–3
Lewinnek et al. advocated an inclination angle of 40 +10
and an anteversion angle of 15 +10 as the safe zone for
cup orientation.4 These goals have been the most widely
Department of Orthopaedic Surgery, Lampang Hospital and Medical
Educational Center, Lampang, Thailand
Corresponding author:
Anuwat Pongkunakorn, Department of Orthopaedic Surgery, Lampang
Hospital and Medical Educational Center, 280 Paholyothin Road,
Mueang District, Lampang 52000, Thailand.
Email: dranuwat@hotmail.com

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2 Journal of Orthopaedic Surgery 27(1)
used targets for several decades although there is contro-
versy in the literature regarding the ideal orientation. The
percentage of acceptably placed cups in the Lewinnek safe
zone varies from 25.7% to 70.5% reported in the literature.5
These outcomes resulted from the conventional method of
cup placement that was guided by intraoperative anatomi-
cal landmarks (free hand technique) or using mechanical
alignment guides. Computer navigation can increase the
percentage of placements in the safe zone up to 81%.6 This
proven advantage must be weighed up against the argument
of prolonged surgery times and higher costs.7
A smartphone that combines features of a personal com-
puter operating system with other features of a mobile
phone is an interesting choice to assist in surgery. The
intraoperative use of smartphone technology in THA for
improving the accuracy of acetabular cup placement was
reported both in cadaveric and in clinical studies. Peters
et al. used the accelerometer and camera function of an
iPhone in a level indicator and protractor application to
improve cup placement in 50 prospective cases.8 They
found good results with all cups being placed within the
Lewinnek safe zone. Kurosaka et al. confirmed this iPhone/
iPad technique in five cadavers and could achieve accep-
table performance in determining the cup alignment
regardless of the surgeon’s expertise.9 However, these two
studies assumed that there are neither preoperative errors in
pelvic positioning nor intraoperative pelvic motion before
cup placement. These conditions are unlikely to be met
during THA.
We developed a pelvic inclinometer that uses the func-
tion of an accelerometer sensor of a downloaded bubble-
level application in a smartphone. This application shows
real-time tilting degrees along two axes. When it is held in
the phone holder and fixed to the pelvis, it can monitor
pelvic motion and present it in a digital number. For mea-
suring the cup inclination, we used another smartphone
with a downloaded angle-meter application. This smart-
phone was placed on top of the cup positioner, and the
alignment guide was pointed parallel to the pelvic inclin-
ometer before final seating. We wanted to investigate
whether this instrument could improve the precision of cup
placement in the Lewinnek safe zone. This study aims to
determine the percentage of acetabular cups that were cor-
rectly positioned in the Lewinnek safe zone, comparing
between the conventional method (using a mechanical
alignment guide alone) and our technique (using a mechan-
ical alignment guide combined with the invented instru-
ment and smartphone).
Materials and methods
A prospective non-randomized, historical-controlled study
was conducted among the adult patients who underwent
cementless or hybrid THA from January 2013 to March
2016 through posterolateral approach by a single surgeon.
These patients were divided into two groups. In the study
group, 41 cups were prospectively placed during January
2015 and March 2016 using a mechanical alignment guide
combined with our invented instrument and smartphone. In
the historical-control group, 41 cups had been placed dur-
ing January 2013 and December 2014 using a mechanical
alignment guide alone. Exclusion criteria were patients
with pelvic deformity or severe kyphoscoliosis.
Our pelvic inclinometer used a smartphone (Lenovo
A390, China) and Smart Level application (version 1.0,
androidboy1.blogspot.com). This program shows real-
time tilting degrees of the smartphone along both the long-
itudinal and the transverse axes. The phone was enclosed in
a zip bag (SunZip, Thailand) and placed in a holder that
was made from a stretchable frame and adjustable adapter
(Yunteng self picture monopod YT-188, China) with a
stem made from an 11-mm diametered stainless tube
(AO/ASIF, Switzerland). The base was a stainless steel
frame with two screw holes at the lower end and a fixed
standard clamp (AO/ASIF, Switzerland) at the upper end
(Figure 1). This frame could be connected firmly and dis-
connected quickly during the surgery (Figure 2).
There were three steps in the smartphone group:
Step 1. The pelvic inclinometer installation. After set-
ting the operating table in neutral position, a skin staple
was put over the tip of the coccyx as a radiographic mar-
ker. The patient was positioned in the lateral decubitus
using two supports (posteriorly over the sacrum and ante-
riorly over the anterior superior iliac spine (ASIS)). The
skin was prepared and partially draped. The inclinometer
was securely fixed to the iliac tubercle by two self-drilling
screws (No.12  2.5 inch, hex washer headed, zinc plated,
Taiwan). The operative field was then covered with a
sterile clear-plastic sheet.
Step 2. Standardization of the patient’s position. The
pelvic position was verified using the cross-table fluoro-
scopy. A plumb was dangled on the image-reception screen
and a long K-wire was taped on the screen to replace this
plumb line (Figure 3(a)). The operating table was tilted so
that the inter-teardrop line was parallel to the K-wire and
the coccyx marker was in line with pubic symphysis. The
C-arm was rotated horizontally until the positional relation-
ship between the superior margin of pubic symphysis and
the tip of coccyx on the fluoroscopic image was the same as
the preoperative supine anteroposterior radiograph (Figure
3(b)). This plane was marked using a cross-line laser level
(a tool commonly used for installing floor tiles) to touch the
flat surface of the C-arm. It projected a laser line, perpen-
dicular to the axis of the C-arm, on the border of the smart-
phone (Figure 4(a)). The thumb-screw knob of the
smartphone holder was loosened and tightened again after
the axis of the smartphone was adjusted horizontally par-
allel to the laser line (Figure 4(b)). The Smart Level appli-
cation was calibrated to the relative position of the phone to
0 along both axes by touching the “calibrate” screen-icon
(Figure 5). The inclinometer was then disconnected from
its base and the surgeon finished draping (Figure 2(b)). For
Pongkunakorn et al.
Figure 1. The pelvic inclinometer comprises (a) a smartphone (enclosed in a zip bag) and a plastic holder (stretchable frame and
adjustable adapter) and (b) a stainless steel tube stem and base.
Figure 2. (a) The upper part of the stainless steel base was firmly connected to the lower part that was fixed into the iliac tubercle by
two screws. (b) It could be disconnected quickly during the surgery.
eliminating the positive effect of fluoroscopy, the operating
table was tilted back to its initial position before starting
the surgery.
Step 3. Control cup positioner and alignment guide.
Before the final cup placement, the inclinometer was
reconnected to its base again, and the operating table was
tilted back to return the pelvis to its standardized lateral
decubitus position by obtain zero tilting degrees shown in
both axes of the Smart Level application. The other smart-
phone (Lenovo A390, China) with the Clinometer applica-
tion (www.plaincode.com) was placed on top and parallel
to the cup positioner. To achieve the 40 target angle of
radiographic inclination, the positioner was moved verti-
cally together with the smartphone until 36 of operative
inclination was shown in the application (Figure 6). The
positioner was then moved horizontally until the mechan-
ical alignment guide, set at 20 of operative anteversion,
3
pointed 5 posterior to the border of the inclinometer smart-
phone by visual estimation before final cup seating.
In the control group, the patient was fixed in lateral
decubitus using two supports after setting the operating
table in neutral position as in the study group. No fluoro-
scopy was used to calibrate the pelvic position. Cup pla-
cement was performed using a mechanical alignment
guide alone at the operative inclination about 40 . The
guide, set at 20 anteversion, was pointed 5 posterior to
the shoulder position of the patient to achieve 25  of
operative anteversion.
In both groups, the posterior capsule and short external
rotators were repaired. Antibiotic prophylaxis was intrave-
nous cefazolin before skin incision and at 6-h intervals for
24–48 h. Two doses of tranexamic acid (500 mg) were
given intravenously, one before skin incision and the other
before closure.
4 Journal of Orthopaedic Surgery 27(1)

Figure 3. (a) A long K-wire was taped on the image-reception screen parallel to the plumb line. (b) Using cross-table fluoroscopy, the
operating table was tilted until the inter-teardrop line was parallel to the K-wire, and the coccyx marker was in line with pubic
symphysis. The C-arm was then rotated horizontally until the relative position of coccyx and pubic symphysis on the fluoroscopic image
was similar to the pelvic radiograph.

Figure 4. (a) The pelvic tilt in sagittal plane of the patient was marked by placing a cross-line laser level on the flat surface of the C-arm.
A laser line was projected beside the border of the smartphone. (b) The smartphone holder was adjusted horizontally until the axis of
the smartphone was parallel to the laser line.

The sample size was calculated to detect a significant
difference in percentage of cup placement in Lewinnek’s
safe zone. We hypothesized that the smartphone technique
can achieve 81% in the safe zone, the same as with com-
puter navigation,6 whereas 52% of our previous THAs were
positioned in the safe zone. With a two-sided type-I error
level of 0.05 and an 80% statistical power of detection, the
sample size was 41 hips in each group.
Preoperative demographic data included patient age,
gender, body mass index, diagnosis, and cup type. Primary
outcomes were radiographic inclination, radiographic ante-
version, and percentage of cup placement in the safe zone.
Pubic symphysis-centered pelvic anteroposterior radio-
graphs were taken in the supine position at 6 weeks post-
operatively. The inclination angle was measured between
the inter-teardrop line and the long axis of the projected
ellipse. The cup anteversion angle was measured and cal-
culated using the Widmer method (Figure 7).10
All radiographic measurements were performed by two
orthopedic residents who were not involved with the
Pongkunakorn et al. 5

Figure 7. Radiograph demonstrating the inclination measure-

ment and the Widmer method for measuring anteversion (ante-
version ¼ 48.05  (2S/TL)  0.3).
Figure 5. (a) The degree of pelvic tilt was shown in the Smart Table 1. Comparison of the baseline characteristics and
Level application. (b) It was calibrated to 0 along both axes by prosthesis data of patients between the two groups.
touching the “calibrate” screen-icon.
Conventional Smartphone
Data (n ¼ 41) (n ¼ 41) p Value

Age
Mean (SD) 51.1 (8.6) 54.5 (7.9) 0.069
Range 36–68 32–67
Gender
M:F 20:21 22:19 0.825
BMI
Mean (SD) 24.1 (4.2) 23.5 (3.8) 0.836
Range 17.4–33.3 17.5–31.1
Diagnosis, n (%)
ONFH 21 (51.2) 19 (46.3) 0.669
DDH 5 (12.2) 6 (14.6)
Inflammatory joint disease 4 (9.8) 5 (12.2)
Femoral neck fracture 1 (2.4) 4 (9.8)
Others 10 (24.4) 7 (17.1)
BMI: body mass index; SD: standard deviation; ONFH: osteonecrosis of
femoral head; DDH: developmental dysplasia of hip.
Figure 6. To achieve 40 radiographic inclination, the positioner
was moved vertically together with the other smartphone until Results
36 of operative inclination was shown in the Clinometer
application. There were 41 patients in each group enrolled in the study.
The patients’ baseline characteristics were not significantly
different between the two groups (Table 1). Plasmafit cups
surgery and repeated again 2 weeks later. The average (Aesculap, Germany) were used in 50 cases (61%) and
of four measurements was used for data analysis. The Trilogy cups (Zimmer, Warsaw, Indiana, USA) were used
intra-class correlation coefficients (ICCs) were calcu- in 32 cases (39%). The mean inclination angle in the smart-
lated for intra-observer and interobserver reliability. phone group was significantly lower than in the conven-
We used the two-way random-effects model and abso- tional group (40.9 (SD 3.8) vs. 46.3 (SD 6.7), p < 0.001).
lute agreement for ICC calculation. The exact probabil- The mean anteversion angle in the smartphone group was
ity test was used to compare categorical data, whereas significantly higher (19.6 (SD 4.4) vs. 16.5 (SD 6.1), p ¼
t-test was used to analyze continuous data, with a 0.010; Table 2). The smartphone group had more cup
p-value of 0.05 being regarded as significant. This placements in the Lewinnek safe zone than the conven-
study was approved by our institutional review board tional group (90.2% vs. 56.1%, p ¼ 0.001; Figure 8). The
and registered in the Thai Clinical Trials Registry. ICC for intra- and interobserver reliability of inclination
Informed consent was obtained from all patients who measurements was 0.97 (95% CI 0.95–0.98) and
participated in the study 0.93 (95% CI 0.91–0.95), respectively. The ICC for intra-
6 Journal of Orthopaedic Surgery 27(1)

Table 2. Comparison of radiographic measurements and Table 3. Comparison of secondary outcomes between the two
percentage in the Lewinnek safe zone between the two groups. groups.

Conventional Smartphone Conventional Smartphone

Data (n ¼ 41) (n ¼ 41) p Value Outcomes (n ¼ 41) (n ¼ 41) p Value

Inclination angle Operative time

Mean (SD) 46.3 (6.7) 40.9 (3.8) <0.001 Mean (SD) 119 (23) 136 (27) 0.011
95% CI 44.2–48.4 39.7–42.1 95% CI 111–128 126–145
Range 28.7–59.0 32.9–48.9 Range 85–160 85–180
Anteversion angle Total blood loss
Mean (SD) 16.5 (6.1) 19.6 (4.4) 0.010 Mean (SD) 822 (266) 885 (340) 0.384
95% CI 14.6–18.5 18.3–21.0 95% CI 726–918 776–994
Range 1.2–23.7 12.3–32.3 Range 400–1530 360–1650
Both in Lewinnek safe zone Dislocation
n (%) 23 (56.1) 37 (90.2) 0.001 n (%) 2 (4.9) 0 (0) 0.494
Surgical site infection
SD: standard deviation. n (%) 0 (0) 1 (2.4) 1.000
SD: standard deviation.

orientation without regard to the safe zone is associated

Figure 8. Comparison of cup positions relative to the Lewinnek
safe zone between the two groups.
and interobserver reliability of anteversion measurements
was 0.84 (95% CI: 0.78–0.89) and 0.82 (95% CI: 0.75–
0.87), respectively. The mean operative time was signifi-
cantly longer in the smartphone group (136 (SD 27) vs. 119
(SD 23) minutes, p ¼ 0.011).
Postoperatively, no significant differences were observed
in total blood loss (p ¼ 0.384), dislocation rate (p ¼ 0.494),
or surgical site infection (p ¼ 1.000). The duration of follow-
up was at least 2 years in all cases. Posterior dislocation
occurred in two hips in the conventional group (Table 3).
All of these had a cup orientation outside the safe zone. One
hip in the smartphone group had superficial wound infection
and was treated by local debridement.
Discussion
The acetabular component positioning is one of the
most important outcome measurements in THA. The cup
with poor outcomes, such as instability, accelerated wear,
adverse local tissue reactions, tendinitis pain, and restricted
range of motion.11 Various definitions of safe zones have
been advocated by both clinical and biomechanical studies.
These safe zones vary between 20 and 55 inclination and
0 and 40 anteversion.12 Among these, the most accepta-
ble target was described by Lewinnek et al.4 Argument
whether this zone is ideal remains controversial. In a retro-
spective study by Abdel et al., the cup orientations in the
majority of dislocated THAs were within the Lewinnek
safe zone.13 Similarly, a systematic review found that the
Lewinnek safe zone is not suitable with respect to the risk
of dislocation. Most articles assessing cup placement
within the Lewinnek safe zone did not show a statistically
significant reduction in dislocation rate.14 Nevertheless,
Elkins et al. conducted a finite-element analysis model and
proposed the optimal landing zone to maximize stability
and minimize wear.12 In general, their ideal cup orientation
is 42.5 + 5.5 inclination and 17 + 5 anteversion.
Similar to a recent large cohort study, Danoff et al. rede-
fined the posterior approach safe zone to be 30 –50 incli-
nation and 10 –25 anteversion.15 Their sweet spot safe
zone (without dislocation) is 41.4 + 4.3 inclination and
17.1 + 4.3 anteversion. The optimal zones in both stud-
ies are narrower but remain within the Lewinnek safe zone.
There are three major causes of acetabular component
malposition, namely, preoperative errors in the pelvic posi-
tioning, intraoperative changes in the pelvic tilt, and intrao-
perative errors in the manual operation.16 The first cause
can be solved using cross-table fluoroscopy to verify the
pelvic position in lateral decubitus. The operative table is
tilted in the coronal (abduction and adduction) and trans-
verse planes (anteversion and retroversion) of the patient
until the pelvic fluoroscopic image is symmetrical and per-
pendicular to the floor. For the sagittal plane (flexion and
extension), the C-arm is rotated horizontally until the
Pongkunakorn et al.
positional relationship between the pubic symphysis and
coccyx on the fluoroscopic image is similar to the preo-
perative radiograph. This plane can be marked by adjusting
the lateral border of the smartphone to be parallel to the
laser line, projecting perpendicularly from the C-arm as in
our technique, or by marking the C-arm orientation on the
floor with tape so that it can be seen clearly during the
surgery as described by Nishikubo et al.16 They used this
technique to correct the errors of pelvic tilt through repo-
sitioning of the operating table using fluoroscopy before
surgery and could place the acetabular component within
an adequate zone (inclination 30 –50 and anteversion
10 –30 ) in 84.3% of hips.
The second cause of cup malposition can be solved by
our pelvic inclinometer. After the patient position is stan-
dardized in lateral decubitus, this position is memorized in
the smartphone application by calibration to 0 . Intraopera-
tive pelvic motion can be assessed by the level application,
and the pelvis can be repositioned to 0 of tilting before cup
placement, by turning the operating table. This is the same
principle as the gravity-assisted guidance system studied by
Echeverri et al.17 and the pelvic tilt goniometer used by
Asayama et al.18 Echeverri et al. used a bull’s-eye bubble
level fixed to a Shanz pin and placed in the iliac crest. It
acts as a reference, identifying the initial yaw and roll
positions throughout the operation. 17 However, the
mechanical bubble level does not show a degree of tilting
and could not be calibrated to 0 at any position of the
device. Asayama et al. used a specially devised goniometer
to measure pelvic motion in real time during surgery. The
device incorporated a digital compass with two goni-
ometers as well as a pendulum and target apparatus. It was
fixed to a threaded Steinmann pin that inserted into the
ASIS.18 They suggested that the surgeon was better able
to accurately achieve the desired cup placement with the
real-time visual feedback about the pelvic orientation and
motion. Nevertheless, their pelvic tilt goniometer is more
complicated, larger, and heavier than our invented inclin-
ometer. Fixation to the pelvis with only one threaded pin
might be weaker than with two screws. Our device can be
disconnected and does not interfere with the operative field
during surgical exposure.
The intraoperative errors in the manual operation can be
solved by our technique that uses a smartphone combined
with an alignment guide. The smartphone is placed parallel
to the cup positioner, and inclination measurement can be
done following the previously described method.8,9 Peters
et al. advocated the operative inclination at 40 from their
surgical experience,8 while Kurosaka et al. recommended
38 following the Murray’s equation and cadaveric study
with the Orthopilot navigation system.9,19 Both studies
aimed the 15 target of radiographic anteversion. Our tech-
nique aimed 36 operative inclination and 25 operative
anteversion following the Murray’s equation to achieve
the targets of 40 radiographic inclination and 20 radio-
graphic anteversion.9 It provided an average of 40.9
7
inclination and 19.6 anteversion in postoperative radio-
graphs of this study.
The percentage of acetabular cups positioned in the
Lewinnek safe zone was significantly higher in the smart-
phone group. The scatterplots showed less scattered dis-
tribution of cup orientation than in the conventional
group. These improved inclination and anteversion angles
came from the use of both smartphones because the pos-
itive effect of fluoroscopy for pelvic standardization was
eliminated by the return of operating table to its initial
position before starting the surgery. It could be assumed
that the pelvic position at the time of skin incision was not
different between groups. Two hips in the conventional
group had posterior dislocation. One of them had antever-
sion of 1 and the other had inclination of 54 . We found
no significant difference in dislocation and infection rates
between the two groups, and this might be from the inad-
equate sample size. The calculated sample sizes with 80%
power to compare the dislocation and infection outcomes
at the same rates require 194 and 410 hips in each group,
respectively. Nevertheless, this study has a power of
95.1% (type I error 5%) to detect the outcome of safe
zone outliers.
There are some limitations in this study. Firstly, it was
not a concurrent study and so might be biased by the
period effect especially from surgeon experience. How-
ever, those THAs in the conventional group were per-
formed by the same surgeon who had passed the
learning curve of such operations more than 10 years pre-
viously. Secondly, our technique had some complexity
that needed a learning curve for fluoroscopic control and
instrument installation. The outcome might be better if the
surgeon is familiar with them. Thirdly, we measured
radiographic anteversion angles using the Widmer
method,10 which might have variation in each measure-
ment. Currently, reformatted CT scan is considered to be
the gold standard for cup anteversion measurement,20 but
it needs special software that is not available in our hos-
pital. However, measurements using the Widmer method
are the most similar to those using reformatted CT, with a
mean difference of 0.9 .20 The ICC for reliability of
anteversion measurements in this study was also at a good
level. To the best of our knowledge, this is the first clinical
study that uses a smartphone as a pelvic tilt goniometer.
Moreover, our method is a novel technique for cup orien-
tation in the Lewinnek safe zone and capable of solving
three major causes of cup malposition.
Conclusion
Using the computerized function of smartphone could
improve the precision of cup positioning in THA. It can
be used with different cup positioners of different compa-
nies in the lateral decubitus position. Most acetabular cups
were placed within a narrow margin inside the Lewinnek
safe zone.
8 Journal of Orthopaedic Surgery 27(1)
Acknowledgment
The authors would like to thank Andrew Sherratt for his help in
approving the English language use.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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